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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003936
Report Date: 07/14/2022
Date Signed: 07/14/2022 12:07:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220401115115
FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Medication: Facility staff are not properly trained to dispense medications.
Neglect/Lack of Supervision: Facility failed to seek timely medical attention for resident after sustaining a fall.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Tender Home Senior Care RCFE on 7/14/22 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. LPA reviewed file of staff responsible for medication identified as S2 and observed S2 had received 5 hours of annual medication administration training dated 3/30/22. LPA observed that S2 was three hours of training short of the required 8 hours of training per the California Health and Safety Code.

Report continued on LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20220401115115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
VISIT DATE: 07/14/2022
NARRATIVE
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Additionally, based on the interviews conducted with S1, S2, R1, and A1 and facts related to R1's injury sustained at the facility the second allegation of Neglect/Lack of Supervision is also substantiated. Facility staff members and reporting party all acknowledged R1 sustained a fall on 2/21/22. Facility staff members all denied any other falls occurring for R1. On 3/10/22 a home health aid observed bruising and swelling on R1's ankle and R1 was transported to the hospital where she was diagnosed with a broken ankle. The department has determined the bruising and swelling should have been observed in routine care of R1 prior to discovery by home health aid over 1 week after the documented fall.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication and Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220401115115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
HSC
1569.69(b)
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Employees assisting residents with self-administration of medication; training requirements: Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours
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Facility will conduct the remaiining medication training for all staff who administer medications to residents. Licensee will ensure all staff members are trained on medications in accordance with regulations of the health and safety code.
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 of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by training records for S2 only contained 5 hours of annual training instead of the required 8 which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
07/15/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health
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Facility will develope a weekly resident checklist where staff members will inspect residents during routine care and documents any observed changes for the Licensee to review and recommend changes.
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condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by the injury sustained and bruising observed by home health aid after the date of the reported fall by R1 and the injury was not reported or observed prior to Home health aid which poses an immediate health, safety and personal rights risk to reidents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220401115115

FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Medication: Medications are not dispensed as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Tender Home Senior Care RCFE on 7/14/22 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because Resident 1 sustained a fall on 2/21/22 and following discovery of ankle fracture was prescribed pain relief medications. The facility began to prescribe the medications as directed by the physician. Interview with A1 claims R1 had an adverse reaction to the medication which was not corroborated by interview with R1. A1 gave verbal orders to change the medication without a physician order so the staff members could not change the amount of medication given to R1. One week later A1 provided the facility with a physician's order to reduce the pain medication and the facility followed the new physician order when administering the medications.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220401115115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
VISIT DATE: 07/14/2022
NARRATIVE
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The Department has investigated the complaint alleging Medications. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220401115115

FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Neglect/Lack of Supervision: Residents not receiving adequate care due to insufficient of staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Tender Home Senior Care RCFE on 7/14/22 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because three of the four authorized representatives for facility residents all denied any issues with residents care and supervision. LPA was able to interview three of the five residents including the alleged victim who all denied they are not receiving adequate care. With the exception of the reporting party all authorized representatives interviewed expressed praise for the facility and staff and also praised the level of care and communication between the facility and family members. LPA observed the facility to be clean and well maintained and all residents appeared clean and dressed in clean clothing. LPA also observed the facility to have no malodorous odor. LPAs review of LIC 500 and availvable staff members include several staff members and family members associated to the facility with annual training on file for all staff members.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20220401115115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
VISIT DATE: 07/14/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7